Inspection on 15/01/08 for Elms, The

This inspection was carried out on 15th January 2008.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Elms, The 12/01/09

Elms, The 27/03/07

Elms, The 28/02/06

Elms, The 15/09/05

Elms, The 15/03/05

Elms, The 17/11/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Elms, The 147, Barry Road London SE22 0JR Lead Inspector Mary Magee Unannounced Inspection 10:00 15th &16 January 2008 th X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Elms, The DS0000007086.V353797.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Elms, The DS0000007086.V353797.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Elms, The Address 147, Barry Road London SE22 0JR Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0208 693 4622 0208 693 9403 care.manager@virgin.net None South East London Baptist Homes Susan Baterip Care Home 25 Category(ies) of Dementia (0), Old age, not falling within any registration, with number other category (0) of places Elms, The DS0000007086.V353797.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th March 2007 Brief Description of the Service: The Elms care home is registered to provide care and accommodation for up to 25 older people. The home has been managed by South East London Baptist Homes since it first opened in 1953. The premises is a large detached house with a single storey extension to the rear. Bedrooms are single occupancy. Communal space includes two lounges, a conservatory and a dining room. The home has a large, well-maintained garden to the rear and off street parking is available. The home is located in a residential road in East Dulwich and close to local amenities such as a library, shops and several bus routes. The work of the home is based on Christian principles and it is stated in the home’s Statement of Purpose that Christians from any denomination may apply. The aim of the home is stated as: ‘to provide a secure, comfortable and caring home for residents, so they can spend the rest of their days in peace and security. We provide comfort and support in a Christian atmosphere where mutual help and friendship are encouraged.’ The current fees for the home are between £500 and £550 a week. These charges do not include the costs of hairdressing, newspapers or toiletries. Elms, The DS0000007086.V353797.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection lasted over two days. The registered manager, the deputy manager and four members of staff were spoken with. One of the trustees was also resent in the afternoon and presented the plans for the refurbishment programme. Throughout the day seven residents told the inspector of their experiences of living at the home. Completed written questionnaires were also received from six residents. Three relatives were also spoken with. A completed self-assessment questionnaire was received from the home. A selection of records was examined, these included maintenance records, personnel files for five staff, also written records for two residents. A tour of the premises was conducted; all the communal areas were seen as well as the bedrooms, the kitchen and laundry. What the service does well: What has improved since the last inspection? Care planning has improved with more consideration given to the spiritual and cultural needs of residents. Elms, The DS0000007086.V353797.R01.S.doc Version 5.2 Page 6 Medication procedures are safe, all documentation in use to record medicines administered is clear and legible. Some internal decoration has taken place; the dining room was redecorated and now appears bright and attractive. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Elms, The DS0000007086.V353797.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Elms, The DS0000007086.V353797.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 2 3 5 6 Quality in this outcome area is good, This judgement has been made using available evidence including a visit to this service. Residents live in a home where the emphasis is placed on providing a caring environment and where the staff have the necessary skills and experience to meet these needs. To avoid inappropriate admissions consideration is needed to developing a more comprehensive needs assessment. EVIDENCE: In case tracking the quality of care delivered the referral and admission process was examined. Prospective residents are given information about the home and the services available through providing an application pack. The pack includes a range of documents including the residents’ guide and letter of contract. Potential service users are visited by senior staff and invited to spend a day at the home. Staff are good at assisting new residents to settle into their new environment, two of the residents expressed the difference this has made, Elms, The DS0000007086.V353797.R01.S.doc Version 5.2 Page 9 they said “staff help residents adapt to their new surroundings, they are very supportive”. For two of the residents admitted in the past twelve months there is evidence of the how decisions were reached to select this home. Both residents are selffunding and have contracts in place stating terms and conditions. One lady admitted in recent months was familiar with the service. She had given over twenty years service there as a volunteer tending to the garden. Family members were present and spoke of “the resident knowing and deciding herself that this was the right service for her”. According to her friends another resident selected the home because of the christian ethos and the caring approach experienced, the following quote was received “she choose to be in a home where staff really care”. The needs of residents are always assessed prior to admission. The assessments include a personal profile, medication profile and a brief medical history. The home demonstrates that it has a skilled and experienced staff team available to meet the needs of residents. All the residents spoken to report favourably on the quality of life experienced and are satisfied that they made the right decision. “It is comforting to know that there are experienced staff on hand twenty four hours a day to help”, “following consultation with the physiotherapist staff helped me with my exercise regime when I injured my shoulder” these comments reflect how residents feel about the service. Changes have taken place though in the dependency levels of new admissions. In recent times residents referred to or admitted to the Elms have more complex needs. The needs assessment format is limited and is not making appropriate provision for the assessment process. A resident was admitted in 2007 with cognitive impairment due to dementia. The needs assessment did not include a report from the CPN. It has however been received since then. The assessment process needs to be expanded and to take into account these needs. Information from other professionals such as a CPN must also be sought and used to determine needs assessments. A requirement is stated. A requirement is stated. . Elms, The DS0000007086.V353797.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good, This judgement has been made using available evidence including a visit to this service. Residents are treated with privacy and dignity and valued as individuals. The care and support arrangements experienced are good. Care staff are familiar with residents and understand the support needed to meet their assessed needs. Care plan documentation is too brief and not always reflecting fully the support needed. EVIDENCE: The care and support arrangements for two residents were case tracked. Both residents moved into the home in the past twelve months. Care plans have been agreed and drawn up for both residents; these are based on needs assessments. As discussed in outcome group “Choice of Home” the pre admission assessments need o be developed further and include full information on all areas where support and care is needed. Since admission additional information was received for one of residents from the CPN and is held with the care plan. Elms, The DS0000007086.V353797.R01.S.doc Version 5.2 Page 11 It was found that consideration is given to recognising and meeting residents’ needs including physical and social needs. Care staff spoken to were able to describe the support needed by both residents. Staff have an overall understanding of the needs of people with dementia. they were seen to be patient and kind when interacting with them. Residents and visitors spoken to confirmed this. In response to a requirement stated in the last inspection report more consideration is given to recognising and responding spiritual and cultural needs. However the care plans are not as detailed as they should be, they still need to be further developed so that appropriate care arrangements are recorded and in place to fully meet all the needs of residents. One resident experiences dementia and is cognitively impaired, the care plan records that there is dementia but does not refer to any cognitive impairment. Neither has the care plan been evaluated regularly to reflect any changes that arise. Daily records are consistently maintained that demonstrate the residents progress. The care plan for the second resident has been kept under review. She was recently admitted, and it is reflecting the current needs and support. A Requirement is stated. The registered person must ensure that written care plans are prepared as to how residents ‘ needs in regard to health and welfare are to be met, these plans need to be kept updated so that they reflect any changes in support arrangements. Staff have the competencies and skills to meet the needs of current residents. They received training on supporting residents with dementia and communicate this information verbally; they are also competent at monitoring and responding to emotional needs. Care staff were seen addressing and comforting a resident that felt a little emotional and needed reassuring. The home does not operate a key working system, this works effectively. Staff are assigned to care for residents on a daily basis. They become familiar with all the residents’ needs, as they are rostered to work on shifts both daytime and on nights. This helps maintain consistency and continuity in the service. Healthcare is promoted. Residents are registered with a GP that visits the home every two weeks. According to residents and staff the service is good. Residents that choose to may register with other practices. Residents consult with other healthcare professionals and receive support to attend hospital appointments. Consultation takes place with chiropodists, dentists. Due to demand there are delays in accessing and receiving some statutory facilities such as chiropody. This is supplemented by private services that residents contribute to. It is evident from feedback from staff and from observations that staff are excellent at promoting privacy and dignity. Residents indicated that the home has a very strong commitment to maintaining privacy, respect and dignity. Training is given to all staff in giving personal care. The staff team has experienced some changes, new staff Elms, The DS0000007086.V353797.R01.S.doc Version 5.2 Page 12 recruited have experience and the skills and reflect in practiced the ethos of the service. The benefits of a good staff team are evident. Staff know individuals well, their preferences and respect their needs and wishes. Residents that choose to enjoy their own company or entertain visitors in their rooms A telephone is provided in a booth by the corridor. A number of residents have their own personal telephone. Residents are supported to promote self-esteem through support with grooming and attire. A hairdresser visits regularly. Clothes are laundered and pressed; residents always wear their own clothes. Residents talk of “ benefiting from kind staff that demonstrate good practice in the home”, they find that as residents they are valued as individuals and each one is shown respect and kindness. This was verified through observation of interactions between staff and residents. Medication procedures were examined as a senior carer prepared to administer medication. Some small important changes were made to documentation. The MAR sheets are well maintained and legible. No omissions of signatures were observed. The medication cabinet is kept locked securely when not in use. Medication received or returned from the home is acknowledged in writing. Elms, The DS0000007086.V353797.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 14 15 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. The home provides a mutually supportive environment that satisfies individual social, religious and recreational interests. Relatives and friends feel included. The home provides well for individual need and preferences. It makes available a variety of excellent home cooked meals that are enjoyed by residents EVIDENCE: The lifestyle offered is in accordance with individual preferences and needs. The home recognises the importance of providing for the spiritual welfare of residents. It meets the spiritual needs of residents by providing a Christian homely atmosphere. As a group both staff and residents foster a spirit of mutual friendship and support where the welfare of others is paramount. Residents spoke of the loss of another resident recently who was over a hundred years old. Members of staff were attending the funeral on the day of the inspection Daily prayers and weekly services are an important part of the communal life of the home. Relatives and friends spoken to during inspection said they are encouraged to come to see their relatives and relatives, and are always made welcome at the home. They are offered light refreshments on visiting. Privacy is respected and Elms, The DS0000007086.V353797.R01.S.doc Version 5.2 Page 14 they are not interrupted unnecessarily. Residents spoke of receiving regular visits from retired work colleagues, members of the church congregation. They also speak to a representative/trustee every month. The majority of residents are familiar to the area and have worked and lived closely for years. They are familiar with local parks and facilities available. Residents and relatives make frequent walks to the park depending on the weather. Resident’s views are taken on board through consultation and quality assurance process. The home has a range of weekly activities available. Religious feasts such as Christmas are celebrated as a group. Activities are planned according to the seasons and weather. Residents speak of enjoying seaside trips and days out in the summer. Residents are able to choose which activities they wish to join in with. The service benefits from the input of volunteers. Activities offered include: arts and crafts, knitting, reminiscence, and exercise classes. Samples of work completed by residents such as greeting cards were seen. Also present are photographs of residents participating in these activities. Residents are also encouraged and enabled to carry on personal interests, for example a resident pursues her interests in the arts by visiting galleries and museums. A mobile library also visits the home. Many residents enjoy reading and crosswords and are able to use the facilities such as the conservatory to do this. A number of residents spoke of still attending the churches they attended prior to admission. They like to retain their contact with local community church groups. A church service is also held every week; many residents like to participate in this. A record of individual interests and activities is recorded on each resident’s file. Although the lifestyle afforded is that preferred by residents more consideration should be given to providing for the needs and capacities of residents that may have some impairments. But for a resident with dementia it was observed that activities available are not always appropriate and are not considering fully her capacity to engage. Additional support is needed in areas of stimulation. Her friends support her by visiting; they find the staff are considerate and caring. A recommendation is made for more attention to needs and capacities and to respond to these with appropriate stimulation. Discussions with the manager, staff, residents and relatives indicate that every effort is to enable individuals to exercise personal autonomy and choice. Some handle their own finances, for others relatives do this. The home does not manage individual finances. They hold for some residents small personal allowances needed for hairdressing or other expenses, for these accounts are maintained of transactions. One resident lacks the capacity to manage her Elms, The DS0000007086.V353797.R01.S.doc Version 5.2 Page 15 own affairs, a power of attorney was appointed some time prior to admission to take control of this. Personal possessions can be brought into the home; evidence of this seen during a tour of bedrooms and when meeting residents. The home recognises the importance of providing good food that residents enjoy. All residents commend highly the quality and variety of food served. They are consulted on preferences, the chefs also try to be innovative and offer new dishes. Menus are varied and nutritionally balanced. The inspector was invited to share lunch with residents. Two sittings take place, as the dining room is unable to accommodate all residents together at mealtimes. Individual preferences regarding mealtimes and sittings, routines of daily living, are respected by staff. Drinks and condiments are provided on the tables. Dining tables are attractively prepared . Those requiring any support at mealtimes receive this. A dessert of a banana sponge and custard followed the lunch of gammon, fresh carrots and mashed potatoes. The food was piping hot; lunch had been freshly prepared in the kitchen. Residents find that the food is always at the right temperature. It was attractively presented and tasted delicious. Residents spoke of appreciating the home cooking and indicate that it is the priority, they made the following comments, “ the food is always fresh, we have homemade cakes too always”, “and nobody could fault the food it is excellent”. Elms, The DS0000007086.V353797.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 18 Quality in this outcome area is good, This judgement has been made using available evidence including a visit to this service. Residents feel safe and find that their views are listened to. The home has effective systems in place to ensure that residents are protected from abuse or neglect. Residents feel confident in the complaints procedures. EVIDENCE: Residents have confidence in the ability of the home and the staff employed to address any concerns they might have. They find that issues can be raised with management, and that these are responded to before they may necessitate a complaint. The complaint’s record was viewed. One complaint is under investigation since 2007. It was referred to the home for investigation. The outcome of this investigation was not available at the inspection. A recommendation is stated. The staff handbook has the codes of conduct expected, also guidelines and rules on gifts or bequests from residents or witnessing of wills. Staff were interviewed during the inspection, they are knowledgeable on policies and procedures that safeguard residents from abuse or neglect. They understand the importance of recognising indicators and safeguarding vulnerable people from abuse or neglect. Staff also showed awareness of the procedures to respond to possible abuse and of the external agencies that should be contacted. There have been no concerns regarding any safeguarding adults issues. All notifiable incidents are notified to CSCI office. Relatives spoke Elms, The DS0000007086.V353797.R01.S.doc Version 5.2 Page 17 of being kept informed of any incidents or concerns regarding residents. The monitoring officer was unable to confirm that incident notifications are made to relevant social workers. The registered person should ensure that incident reports are forwarded to relevant social workers. Individuals take responsibility for managing their own financial affairs where possible. Otherwise relatives or those having power of attorney provide this support. Individuals that choose to have a small amount of money managed in the office. This is used for personal expenses such as hairdressing. Measures are in place to manage this safely and audit this procedure. Elms, The DS0000007086.V353797.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 20 24 25 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The premises are showing signs of wear and tear and need updating. Plans are in place to complete a major refurbishment programme. This programme when completed will make sure that the environment is more comfortable and suitable. EVIDENCE: The home is clean; “staff do an excellent job in keeping the home clean” were representative of comments received from residents. The building offers a homely, comfortable and domestic environment with adequate communal facilities. Bedrooms vary in size and facilities. Some are quite spacious, all those seen were personalised with items of furniture or personal objects. Despite the sense of satisfaction experienced by residents from the homely warm environment there is significant signs that the internal areas of the home Elms, The DS0000007086.V353797.R01.S.doc Version 5.2 Page 19 are appearing more shabby and that significant investment is required. The inspector heard of the plans to improve the physical facilities and improve the environment for residents. The refurbishment programme is planned in two stages. The first phase includes the first floor of the building. The chairman/responsible individual is in negotiations with the housing trust to lease the vacant property next door and to use this when refurbishment takes place. Plans drawn up by the architect were seen of the improvements in the refurbishment of the first floor. Plans make provision to extend the size of some of the single rooms. The organisation is planning to submit an application to CSCI register the premises they plan to use next door. CSCI must be kept fully informed on the progress of the refurbishment programme. Two maintenance persons have begun work at the home on a part time basis. They attend to repairs and are decorating bedrooms and the corridors on the ground floor. No outstanding repairs were noted. The dining has been redecorated. Residents choose the colour scheme. Individuals were observed being consulted on the colour scheme for their bedrooms. Elms, The DS0000007086.V353797.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27 28 29 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home benefits from the employment of caring, kind and sympathetic staff that value people. Training and development is good and equips staff with the skills and knowledge required. There are some shortfalls still in the recruitment procedures that need addressing urgently. EVIDENCE: Appropriate numbers of suitably skilled and experienced care staff are employed and available to support residents lead meaningful lives. Twenty care staff are employed permanently, eighteen of these carers have acquired NVQ level 2 or above. Seven carers began NVQ level 3 in care in the past twelve months. Additional ancillary staff do an excellent job of maintaining good hygiene at the home and keeping the premises clean and completing laundry chores. Catering staff are employed and produce excellent meals that residents enjoy. There have been changes in the staff team over the past twelve months. Six care staff have left employment, the majority were long-term employees and have retired. However the same principals of employing staff with the right attitudes and attributes have ensured that consistency and stability are maintained. Five carers work in the morning in addition to the management team, four carers are available on the afternoon shift. At night there are two night carers on duty, in addition an on call manager is available within the premises. Elms, The DS0000007086.V353797.R01.S.doc Version 5.2 Page 21 A team leader/senior carer leads each shift in addition to management presence. Senior trained staff administers medication. The registered manager has introduced a new induction programme. Workbooks for this were seen. The initial induction was basic and did not include all the elements of the Skills for care specification. New carers were seen shadowing senior more experienced staff and becoming familiar with residents before they undertake tasks alone. Staff confirm an induction is received but the evidence was not present in writing however to confirm that competencies are always assessed and signed off at the end of the induction period. A recommendation is made. Discussions with staff and from observations made of some individual skills records there is evidence that a wide range of training including mandatory training is provided to the staff team. The records of the training are not maintained well, it is difficult to evaluate, as individual training records are not always retained on staff personnel files. Neither is there a matrix maintained of training delivered to identify and respond to individual training needs. A recommendation is made. And the AQQA completed includes details of future training. It is recommended that the training and development programme is developed to reflect individual training needs. Care is needed to make sure that the training focuses on the needs of the residents. Staff files for five new care staff were examined. Two references were available on each file and confirmation of eligibility to work. Shortfalls were found in recruitment procedures, employment histories for one staff member had an unexplained gap, proof of identity was also absent for another new member of staff, Four of the staff files had a CRB Enhanced Disclosure with a POVA check. The fifth member of staff had begun work with a POVA check but before the CRB Enhanced Disclosure was received. According to the manager the member of staff was shadowing a senior member of staff during the induction period. Shortfalls were found in the last key inspection of February 2007. The recruitment procedures must be amended and clearly demonstrate robust recruitment procedures. This is the subject of an Immediate Requirement letter. Elms, The DS0000007086.V353797.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31 33 35 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents enjoy living in a home where their views are respected and help inform the service planning. There are areas of weakness, a lack of a fire risk assessment means that staff are unclear about the frequency of evacuation procedures. EVIDENCE: Discussions with residents, staff, and relatives suggest that that there is a sense of strong leadership from the manager. She is an experienced and skilled manager, she gives stability and reassurance. She is available on call for four evenings a week, using the living accommodation provided for on call managers. Elms, The DS0000007086.V353797.R01.S.doc Version 5.2 Page 23 Both residents and staff feel included in decision-making. They express a sense of feeling valued, respected, listened to. A trustee from the board examines the running of the home every month. Regular unannounced Regulation 26 visits take place, as part of the visit the individual monitors the health and safety risk management, records of these were viewed. Comments received from residents all positively reflect their satisfaction with the service provided. The quality assurance system needs to be explored more fully. The feedback from residents and staff is not utilised fully to monitor and evaluate the service. The previous requirement is restated. Where possible residents handle their own financial affairs. Those requiring assistance receive support from relatives, solicitors or from external sources that have power of attorney. Small amounts of pocket money are held in safekeeping. Systems are in place to manage this effectively. According to records supplied on the AQQA received from the registered manager the following equipment has been serviced as recommended by the manufacturer, Potable electric equipment, the lift, fire detection equipment, gas appliances, and hoist. Records at the home show that weekly testing of fire alarms take place. According to records seen, one fire evacuation procedure has taken place since the last inspection in February 2007 despite a requirement stated in that inspection report. Staff received fire training but there is a lack of clarity regarding regular evacuation procedures and frequencies. There was no fire risk assessment available to examine or determine the frequency of procedures. A requirement is stated in relation to fire risk assessing the premises, this to include the evacuation procedures that are to be adopted. Elms, The DS0000007086.V353797.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 2 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 4 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X 3 2 3 STAFFING Standard No Score 27 3 28 4 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 Elms, The DS0000007086.V353797.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP3 Regulation 14 (1) a, b, cod. Requirement Timescale for action 28/02/08 2 OP7 15(1) 3 OP19 16 (1) 4 OP29 19 The registered person must ensure that the pre admission assessment includes a full needs assessment and that these are recorded. Having regard to the needs assessment confirmation must be given to the resident or representative that the home is suitable to meet these needs The Registered Person must 28/02/08 ensure that the written Care plans are more detailed and reflect the way that the home plans to support and meet all aspects of health, personal and social care needs of residents. 30/05/08 The registered person must ensure that CSCI is kept informed on planned refurbishment programme and accommodation arrangement during the refurbishment period. Relevant application must be made to the Registration team regarding the use of the premises next door. The Registered Person must 28/02/08 ensure that recruitment DS0000007086.V353797.R01.S.doc Version 5.2 Elms, The Page 26 procedures reflect the requirements of NMS 29 and Regulation 19 of the Care Homes Regulations 2001. (This is the subject of an Immediate requirement letter) 5 OP33 24(2) The Registered Person must ensure that the results of the residents’ survey are collated to form a report to be distributed as required by regulation. (Unmet in timescales of 1/07/07) 28/02/08 6 OP38 23(4)(e) The Registered Person must 28/02/08 ensure that residents’ safety is maintained by ensuring that a fire risk assessment is in place. A copy must be forwarded to the inspector of the fire risk assessment. This risk assessment to provide guidance on the frequency of fire evacuation procedures. Current records show that staff are involved in fire drills annually. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP1 Good Practice Recommendations It is recommended that the residents’ guide be amended to include recent feedback about the home so that potential residents can be sure that they are basing their decision on current information. The registered person should ensure that more consideration is given to providing for the individual needs DS0000007086.V353797.R01.S.doc Version 5.2 Page 27 2 OP12 Elms, The 3 4 5 6 OP16 OP18 OP30 OP30 for stimulation, in particular those with dementia. The registered person should ensure that a copy of the report on the outcome of the investigation currently underway is forwarded to CSCI. The registered person should ensure that incident reports are notified to relevant social workers. The registered person should ensure that a staff training and development programme is operated and that records are maintained to confirm this. The registered person should ensure that the induction of staff new staff is verified through an assessment process and that records are maintained to confirm this. Elms, The DS0000007086.V353797.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Elms, The DS0000007086.V353797.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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